NR 511 Week 3: Clinical Case Study Part Two Discussion

NR 511 Week 3: Clinical Case Study Part Two DiscussionWhat is your primary (one) diagnosis for this patient currently? (support the decision for your diagnosis with pertinent positives and negatives from the case) Allergic Conjunctivitis The pertinent information is supported by: 1. Positive data- Patient experienced a quick onset of 2 to 3 days, confirming spring allergies, eye redness, itching, tearing, FM sensation and feels his eyes are gritty. 2. Negative data- Patient did not report having a fever, feeling ill, eye drainage, and sneezing. 2.ICD-10 Code H10.13, Acute atopic conjunctivitis bilateral 3.Treatment plan for primary diagnosis included medication, additional testing, patient education. 1. Loratadine 1tab p.o. daily. Loratadine is used to treat allergy symptoms. It is an antihistamine that lessens natural chemicals known as histamines in the body. Medication should be avoided the if the patient is allergic to Clarinex. (Epocrates Atehna Health 2018). 2. Fluticasone nasal spray 1 spray in each nostril daily, Education- Fluticasone is used to treat seasonal allergies. (Epocrates Atehna Health 2018). 3. Pataday 0.1% instill 1 drop in each eye twice per day Education- Pataday is a antihistamine used in the treatment against allergic conjunctivitis and treats the redness associated with the condition. If patient starts to exhibit signs and symptoms of allergic reaction such as headaches eye irritation wheezing call provider immediately, (Epocrates Atehna Health 2018). 4. Any additional testing necessary for this diagnosis- Allergic Conjunctivitis – Testing can be performed, however very costly. It is not a requirement for diagnosis. 5. Patient made aware of allergic conjunctivitis diagnosis and education provided about how seasonal allergies can cause the symptoms. 6. Patient education provided on the importance of frequent handwashing and to avoid toughing the eyes and face. 7. Patient educated on taking the medications as prescribed and to not use the tip of eye drop bottle to touch eye as it can cause contamination. 8. Educate patient on importance of removing dust from the home in all areas such as windows and ac vents, along with the importance of changing bed linen weekly. 9. Educate patient on using a cool washcloth on eyes to help with irritation sensation. 10. Referral- No referral current 4.Prescriptions and OTC medication were written and given to patient with correct information. 1. Patient to continue to stay on previous medications (Loratadine and Fluticasone) 2. (Pataday), 0.1%, instill 1 gtt in both eyes BID, space doses at least 8h apart, 1 bottle with one Refill #1 5.Treatment plan supported by EBM including medications, testing, referrals. Patient reports his allergies are well controlled with Loratadine and Fluticasone nasal spray taken during peak time. Will continue to these medications.